Author Topic: Know your benefits  (Read 1318 times)

Pay_My_Claims

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Know your benefits
« on: April 17, 2009, 02:43:52 PM »
I just wanted to share this with everyone. Before becoming a medical biller, I was an insurance specialist, which is a plus when it comes to billing. My current employer runs a DME company, and he is oon with a lot of carriers. Well one insurance company denied to give us authorization because we were an oon provider. They told us to have the patient go to an in net provider. I know they are looking out for the patients benefits, but she had a secondary insurance so I knew from that she would be ok. The biller asked me what she should do, and I said give me the chart and let me review it. I verified her insurance, she had met her out of network ded/oop and her insurance would now pay at 100% plus she had Medicare secondary. I called the insurance company, told them the patient wants to use her out of network benefits, and she was at 100% coverage. They gave me the number to fax the paperwork and I wrote a letter stating that fact and we recieved auth. Ok, now the claims adjuster calls to see if we want to make a deal............uh no!!! The patient is fully covered, she is at 100% I declined the offer. Well they processed the claim and paid at 60%. Here I go on the phone calling said insurance company. Oh Ms Hargrove, we apologize and will send the rest of the payment out to you!!!  So Billers, don't just be looking for codes and modifiers to get your client reimbursed fully....be aware of what plan the patient has, and never be afraid to tell  the insurance company to PAY MY CLAIM!!!


Michele

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Re: Know your benefits
« Reply #1 on: April 17, 2009, 09:17:20 PM »
Great advice, thanks for sharing your story.  So many providers accept the payment they receive and don't question it.  I had a very similar situation.  They were suppose to pay 100%, they only paid a portion.  When we called they said, and I quote "we will pay the rest, the patient just needs to call and ask us to".  How many providers/patients never call.  Think of the money they save!

I too worked for a major insurance carrier prior to opening my business.  It is a huge plus.

Michele
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Pay_My_Claims

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Re: Know your benefits
« Reply #2 on: April 19, 2009, 03:52:31 PM »
i actually worked at a medical facility in NC. I did hospital inpatient/outpatient benefits, and authorizations. Prior to that I worked at a family medical office, and I have worked at an Er registrar and unit clerk.